International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Haq AU et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4256-4262

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20164323
Original Research Article

Analysis of risk factors in surgical site infection following

caesarean section
Anam ul Haq1*, Aasif Abdullah1, Shazieya Akhtar2

1
Department of Obstetrics and Gynaecology, SKIMS Soura, Srinagar, Jammu and Kashmir, India
2
Department of Pathology, SKIMS Soura, Srinagar, Jammu and Kashmir, India

Received: 10 September 2016

Revised: 13 October 2016
Accepted: 15 October 2016

*Correspondence:
Dr. Anam ul Haq,
E-mail: anamulhaq801@gmail.com

Copyright: the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Objective of the study was to find SSI rate following Caesarean section and Analysis of risk factors.
Methods: This prospective randomized study carried out on 1504 patients, their demographic information, risk
factors and surgical indications were recorded. Postoperatively patients were monitored for signs of SSI.
Results: Out of 1504 patients, 13% developed SSI, Hospital stay, wound class, ASA class, antibiotic prophylaxis and
Type of caesarean showed significant association with SSI.
Conclusions: Reason for incidence of SSI higher than developed countries being only tertiary care hospital dealing
with high risk pregnancies, late referrals from peripheries, Prolonged hospital stay, heavy rush of attendants, faulty
supervision where dose of antibiotics is actually missed, no proper segregation of cases.

Keywords: ASA class, Hospital stay, SSI, Wound class

INTRODUCTION become increasingly important to obtain accurate rates of

Infection is the clinical manifestation of the inflammatory
reaction incited by invasion and proliferation of
microorganisms.1 SSI is the second most common
infectious complication after urinary tract infection
following caesarean delivery.2 The rates of SSI after
caesarean section reported in the literature range from 3%
to 15% depending on the surveillance method used to
identify infections, the patient population and the use of
antibiotic prophylaxis.3-9 Maternal morbidity related to
infections has been shown to be eight fold higher after
caesarean section than after vaginal delivery.10 Among
hospitals reporting to the National Nosocomial Infections
(NNIS) system, the rate of SSI after caesarean section
was 2.8% to 6.7% depending on the risk index category.11
The incidence rate depends on the following: the
definition of SSI adopted, the intensity of surveillance,
the prevalence of risk factors for SSI in the patient group
being audited and whether the survey contains post
discharge data[12].Post discharge surveillance has
SSI.
Criteria for defining surgical site infections
Superficial incisional SSI
Infection occurs within 30 days after operation and
infection involves only skin or subcutaneous tissue of the
incision and at least one of the following.
1. Purulent discharge from the superficial incision.
2. Organisms isolated from the superficial incision.
3. At least one of these signs or symptoms of infection:
Pain or tenderness, swelling, redness or heat and
superficial incision are deliberately opened by
surgeon, unless incision is culture negative.
4. Diagnosis of superficial incisional SSI by the
surgeon or physician.

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Deep incisional SSI
Infection occurs within 30 days after operation if no
implant is left in place or within one year if implant is in
place and the infection appears to be related to the
operation and infection involves deep soft tissues of the
incision and at least one of the following:
1. Purulent drainage from the deep incision but not
from the organ/space component of the surgical site.
2. A deep incision spontaneously dehices or is
deliberately opened by a physician when the patient
has atleast one of these signs or symptoms of
infection: fever, localized pain or tenderness, unless
the site is culture negative.
3. An abscess or other evidence of infection involving
the deep incision is found.
4. Diagnosis of a deep incisional SSI by a surgeon or
physician.
Organ/space SSI
Infection occurs within 30 days after operation if no
implant is left in place or within one year if implant is in
place and the infection appears to be related to the
operation and infection involves any part of the anatomy,
other than the incision, which was opened or manipulated
during an operation and at least one of the following:
1. Purulent drainage from a drain that is placed
through a stab wound into the organ/space
2. Organisms isolated from fluid or tissue in the
organ/space.
3. An abscess or other evidence of infection is found.
4. Diagnosis or an organ/space SSI by a surgeon or
physician.
Determinants of infection
1. Inoculum of bacteria
2. Virulence of bacteria
3. Adjuvant effects of microenvironment
4. Innate and acquired host defences
Risk factors for wound infection
Host related factors
Socioeconomic status: Low socioeconomic status has
consistently been associated with higher rates of post
caesarean infection.14-16
Preterm delivery: Preterm delivery is a known risk factor
for sepsis; also many preterm deliveries are
emergencies.17
Rupture of membranes: One factor repeatedly linked to
post caesarean infectious morbidity is prolonged rupture
of the membranes because of more chances of
contamination.
International Journal of Reproduction, Contraception, Obstetrics and Gynecology
Vaginal examinations: Prolonged labour increases the
number of vaginal examinations which predisposes the
patient to post-partum infection.18
Surgery related factors
Emergency
Women who underwent an emergency caesarean delivery
for indications such as placental abruption, non-
reassuring fetal heart rate and non progressing second
stage of labour were more likely to develop a wound
infection.19
American society of anaesthesiologists score
The American Society of Anaesthesiologists physical
status classification is a standardized, reproducible
numeric determination that is used routinely to stratify
severity of illness for surgical patients and is known to be
a good indicator of host susceptibility to infection.20,21
Duration of operation
Patients who underwent surgery for more than one hour
constituted another group at risk of infection.22,3
Antibiotic prophylaxis
Prophylactic antibiotics will reduce the incidence of
endometritis following both elective and non-elective
caesarean delivery by two thirds to three quarters and the
incidence of wound infection by up to three quarters.7
METHODS
This study was a prospective design study conducted on
1504 patients selected randomly from August 2014 to
October 2015 in Lalla Ded Hospital Srinagar J and K.
Inclusion criteria
1. Patients who had undergone caesarean in this hospital
Exclusion criteria
1. Any patient operated elsewhere
Purpose of study was explained to patients, and their
verbal consent taken.
Data collection
Demographic information, potential risk factors and
surgical indications were recorded.
Postoperatively women were monitored for signs of
infection. Temperature was measured every day and
leukocyte count was done if the patient developed fever
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(temp over 38.0C). Wound culture was not done
routinely unless infection was suspected.
The surgical site was considered infected if pus was
found anywhere along the suture line with or without
dehiscence.
Data analysis
Majority of cases (45.9%) had class I wound, whereas
21.6% had class II wound; 27.1% had class III wound
and 5.4% had class IV wound.
Majority of cases (48.2%) were with mild systemic
disease, whereas 33.8% were normally healthy, 12.8%
with severe systemic disease and 5.3% with
incapacitating systemic disease.

Data was expressed as MeanSD and percentages.
Critical difference of variance for metric data was
measured at 95% confidence interval by students t test.
Non metric data was similarly analysed by Fishers exact
test, Mann-Whitney U test, besides logistic regression
analysis was done for determining best predictors along
with Odds ratio analysis. P 0.05 considered statistically
significant. Statistical SPSS, Mini Tab and MS Excel
were used for data analysis.
Majority of caesareans (66.3%) were emergency and
(33.7%) were elective.
Maximum number of cases (88.9%) had received
prophylactic antibiotics whereas (11.1%) had not
received any prophylactic antibiotics.
Majority of cases had superficial (64.1%) whereas
(24.6%) had deep and (11.3%) had organ/space SSI.

Definitions Table 1: Various risk factors of SSI.

American Society of Anaesthesiologists Score (ASA) n %

24 406 27.0
Class I - Normally healthy patient. 25 to 29 777 51.7
Class II - Mild systemic disease. Age (yr) 30 to 34 284 18.9
Class III - Severe systemic disease. 35 37 2.5
Class IV - Incapacitating systemic disease that is mean SD 26.93.4 (18, 40)
threat to life. Class I 690 45.9
Class V - Morbid patient who is not expected to Class II 325 21.6
survive 24 hours. Wound Class
Class III 408 27.1
Class IV 81 5.4
Wound class
Normally healthy 508 33.8
Class I - No rupture of membranes or labour. Mild Systemic
725 48.2
Class II - If there was less than 2 hours of Disease
ASA
membrane rupture without labour or labour of any Severe systemic
classification 192 12.8
length with intact membranes. disease
Class III - For rupture of membranes greater than 2 Incapacitating
79 5.3
hours. systemic disease
Class IV - For purulent amniotic fluid. Prophylactic No 167 11.1
antibiotics
Prior to Incision 1337 88.9
RESULTS given?
Elective 507 33.7
Operation type
Demographic information, potential risk factors and Emergency 997 66.3
surgical indications were recorded. Superficial 125 64.1
Type of SSI
Deep 48 24.6
Host related variables included age, preoperative Organ/Space 22 11.3
diagnosis, a preoperative condition assessed by American 16 to 30 days 12 0.8
Society of Anaesthesiologists (ASA) score and total 4 to 7 days 594 39.5
hospital stay. Total hospital
8 to 15 days 630 41.9
stay (day)
16 to 30 days 268 17.8
Surgery related variables included nature of the
>30 days 12 0.8
operation, wound class and antibiotic prophylaxis.
Surgical Site Yes 195 13.0
Majority of the cases (51.7%) were in age group of 25 to Infection (SSI) No 1309 87.0
29 years, whereas 27% were <24 years; 18.9% between
30-34 years and 2.5% cases were >35 years. Majority of cases (41.9%) had total hospital stay of 8 to
15 days, whereas (39.5%) had total hospital stay of 4 to 7
days, 17.8% stay of 16 to 30 days and 0.8% stay of more
than 30 days.

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 Haq AU et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4256-4262

Out of total 1504 cases 195 developed SSI and rate was (21.5%) developed SSI out of 79 cases that had
13 % (Table 1). incapacitating systemic disease. The above results depict
that SSI is more prevalent in cases associated with
In our study (8.3%) cases developed SSI out of 690 cases morbidity with higher class ASA, with P value being
of class I wound, (14.2%) developed SSI out of 325 cases 0.000, which is statistically significant (P <0.05); [OR
of class II wound; (18.1%) developed SSI out of 408 1.92] (Table 3).
cases of class III wound and (22.2%) developed SSI out
of 81 cases of class IV wound. The above results depict Table 2: Association of wound class with SSI.
SSI is more prevalent in contaminated wound class with
P value of 0.000 which is statistically significant (p<0.05) Yes No p
OR
[OR 2.01] (Table 2). n % n % value
Class I 57 8.3 633 91.7 0.4
In ASA classification of patients (9.4%) developed SSI Wound Class II 46 14.2 279 85.8 0.000 1.1
among 508 cases that were normally healthy; (13.5%) class Class III 74 18.1 334 81.9 (Sig)* 1.8
among 725 cases who had mild systemic disease; (6.7%) Class IV 18 22.2 63 77.8 2
among 192 cases that had severe systemic disease and * Significant

Table 3: Association of ASA with SSI.

Yes No
p value OR
n % n %
Normally healthy 48 9.4 460 90.6 0.6
Mild systemic disease 98 13.5 627 86.5 0.000 1.1
ASA classification
Severe systemic disease 32 16.7 160 83.3 (Sig)* 1.4
Incapacitating systemic disease 17 21.5 62 78.5 1.9
* Significant
Table 4: Association of prophylactic antibiotics. cases who had received prophylactic antibiotics, (11.1%)
developed SSI. The above results depict that SSI is more
Prophylactic Yes No prevalent in cases who had not received prophylactic
p antibiotics, with a P value of 0.000, which is statistically
antibiotics OR
n % n % value significant (p<0.05); [OR 3.03] (Table 4).
given
No 46 27.5 121 72.5 5.1
0.000 Operation type showed that among 507 elective cases,
Prior to
149 11.1 1188 88.9 (Sig)* 0.2 8.7% developed SSI while from 997 emergency cases,
incision
* Significant 15.1% developed SSI. The results depict that SSI is more
prevalent in emergency caesareans with a P value being
Among 167 cases who had not received prophylactic 0.000, which is statistically significant (P <0.05) [OR
antibiotics, (27.5%) developed SSI while out of 1337 1.88] (Table 5).

Table 5: Association of operation type with SSI.

Yes No
p value OR
n % n %
Elective 44 8.7 463 91.3 0.5
Operation type 0.000 (Sig)*
Emergency 151 15.1 846 84.9 1.9
* Significant

Table 6: Association of hospital stay with SSI.

Yes No
p value OR
n % n %
4 to 7 days 28 4.7 566 95.3 0.2
Total hospital stay 8 to 15 days 52 8.3 578 91.7 0.5
0.000 (Sig)*
(day) 16 to 30 days 103 38.4 165 61.6 7.8
>30 days 12 100.0 0 0.0 171.7
* Significant

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 Haq AU et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4256-4262
Out of 594 cases who had total hospital stay of 4 to 7
days, 4.7% developed SSI; 630 cases who had total
hospital stay of 8 to 15 days, 8.3% developed SSI; 268
cases who had total hospital stay of 16 to 30 days, 38.4%
developed SSI and among 12 cases who had total hospital
stay more than 30 days, 100% developed SSI. The above
results depict that SSI is more prevalent in cases with
prolonged hospital stay with P value of P = 0.000; [OR
171.60] which is statistically significant (Table 6).
DISCUSSION
The overall abdominal wound infection rate of 13% is
comparable with other studies that have used post
discharge surveillance. Similar findings were observed by
Barbut F, Carbonne B, Truchot F et al and Mitt P, Lang
K, Peri A et al, which found significant percentage of SSI
is detected by post discharge surveillance.23,24
Due to referrals from other hospitals, patients fall in
higher wound class either because of prolonged labour,
prolonged rupture of membranes or obstructed labour
which is a potent risk factor for SSI when caesarean
section is done.
In our study Among 690 cases of class I wound, 8.3%
developed SSI. Out of 325 cases of class II wound,
14.2% developed SSI. Among 408 cases of class III
wound, 18.1% developed SSI and from 81 cases of class
IV wound, 22.2% developed SSI. The above results
depict that SSI is more prevalent in cases with more
contaminated wound class. Similar findings were
observed by Eriksen H, Saether AR et al, Amenu
Demisew, Tefera Belachew et al, Mitt P et al, Jido TA,
Garba ID et al, Killian CA et al, and Schneid Kofman N
et al which showed significant association between
surgical wound class and SSI.3,19,24-27
Our hospital being a sole tertiary care hospital in valley
and most of the patients who are referred from
pheripheries are usually high risk pregnancies with higher
ASA class, which is a significant risk factor for SSI. In
our study, Out of 508 normally healthy cases (9.4%)
developed SSI. Among 725 cases with mild systemic
disease (13.5%) developed SSI, Within 192 cases of
severe systemic disease, (16.7%) developed SSI and from
79 cases who had incapacitating systemic disease,
(21.5%) developed SSI. The above results depict that SSI
is more prevalent in cases associated with morbidity.
Similar findings were observed by Tran ST et al and
Barbut F, Carbonne B, Truchot et al, which showed
significant association between ASA class and SSI.4,23
Numerous studies have recommended that antibiotic
prophylaxis be given to all caesarean delivery cases for
prevention of serious infections.
In our hospital we have a protocol of giving antibiotic
prophylaxis to all women undergoing caesarean section.
We found all elective caesareans had received
International Journal of Reproduction, Contraception, Obstetrics and Gynecology
prophylaxis before procedure, but it was found that not
all emergency caesareans had received prophylaxis
before procedure; reason was either nursing staff had not
given or it was not prescribed on case sheet. Results from
our study showed among 167 cases who had not received
prophylactic antibiotics, (27.5%) developed SSI and out
of 1337 cases who had received prophylactic antibiotics
(11.1%) developed SSI. The above results depict that SSI
is more prevalent in cases who had not received
prophylactic antibiotics. Similar findings were observed
by Beattie, Rings TR et al, Owens SM et al and Killian
CA et al.3,28,29
Emergency caesarean sections are done usually when
patient is in labour; mostly membranes are absent,
increased number of vaginal examinations and sometimes
miss the dose of prophylactic antibiotics. All these are
potent risk factors for infection. In our study 8.7%
developed SSI, out of 507 elective caesareans and 15.1%
developed SSI out of 997 emergency caesareans. SSI was
more prevalent in emergency caesareans with P value
being 0.000; [OR 1.9] which is statistically significant
(p<0.05). The above results are consistent with studies of
Schneid-Kofman N et al and Amenu Demisew, Tefera
Belachew et al.19,26
Prolonged stay in hospital means more chances of
infection because of cross infection by health care
workers, poor sanitation and poor asepsis. In our study
out of 594 cases who had total hospital stay of 4 to 7
days, 4.7% developed SSI; 630 cases who had total
hospital stay of 8 to 15 days, 8.3% developed SSI; 268
cases who had total hospital stay of 16 to 30 days, 38.4%
developed SSI and among 12 cases who had hospital stay
more than 30 days, 100% developed SSI. The above
results depict that SSI is more prevalent in cases with
prolonged hospital stay with P =0.000 [OR 171.60] which
is statistically significant. The above results are consistent
with the study of Nisa M, Naz T, Afzal I et al.30
CONCLUSION
The caesarean delivery rate has been steadily increasing
over the last 30 years and it is common for major centres
to have a rate in double figures. The development of a
wound infection after caesarean delivery is a morbid
event and may result in significant patient discomfort,
inconvenience, embarrassment, prolonged hospital stay,
additional surgery and increased cost of community care
following discharge.
Incidence of SSI was (13%) following caesarean section
which is higher than developed countries.
Statistically significant risk factors for SSI include wound
class, ASA class, Antibiotic prophylaxis and operation
type and total hospital stay.
The various reasons for such increased rate of SSI are:
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1. Only tertiary care institute dealing with high risk 8. Yokoe DS, Christiansen CL, Johnson R.
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Cite this article as: Haq AU, Abdullah A, Akhtar S.
Analysis of risk factors in surgical site infection
following caesarean section. Int J Reprod Contracept
Obstet Gynecol 2016;5:4256-62.
Volume 5 Issue 12 Page 4262